2 854 La Revue de Santé de la Méditerranée orientale, Vol. 15, N 4, 2009 Introduction Vitamin is an essential vitamin derived from food of animal origin. The recommended average daily intake for adults is 2 4 μg [1]. The liver is the largest reservoir for in the body; it stores up to 3 mg, which is sufficient for several years before the neurological and haematological sequelae of become evident [2]. is a common but under-recognized disorder with a prevalence of 3% 40% in the adult population [3 7]. There is, however, considerable debate concerning the definition of the lower limits of vitamin levels in healthy adults [8,9]. Prevention of micronutrient enhances human development and economic wellbeing. The rate of anaemia among women of childbearing age in Jordan is 32% and the rate among children is 20% according to the results of a joint study conducted by the Jordanian Ministry of Health, United Nations Children s Fund (UNICEF) and the World Health Organization (WHO). The study highlights the importance of regular monitoring of micronutrient status in young children (< 5 years) and women of childbearing age (15 49 years) in Jordan. UNICEF and WHO embarked on a flour fortification campaign in As a result, bread has been fortified with iron and other micronutrients such as vitamin A. We aimed to estimate serum vitamin levels in patients attending clinics at Jordan University Hospital in Amman, and to examine any relationship between demographic data, chronic illness, dietary habits, haematological parameters and symptoms related to levels. Methods All patients presenting to the family medicine clinic and the diabetic foot clinic at Jordan University Hospital from October 2005 to January 2006 were evaluated for vitamin. Attendees at family medicine clinics are mostly healthy adults coming for minor ailments, acute problems or administrative reasons; a few have chronic illness. Patients attending the diabetic foot clinic are by definition suffering from a chronic illness. The 2 groups were chosen to ensure representation of both healthy and ill adults. A total of 838 adults aged years were included in the study (18 years was the cut-off). All persons attending the 2 clinics were offered the chance to be included in the study. Exclusion criteria were pregnant females, patients currently on vitamin or any other multivitamin supplements and those on anticonvulsant drugs. Informed consent was obtained from each participant and the study was approved by the scientific research committee at the Faculty of Medicine, University of Jordan. The data collected included age, sex, presence of any chronic illness and dietary habits. Chronic illness was defined as any disease lasting more than 3 months, such as diabetes mellitus, hypertension, coronary artery disease, hyperlipidaemia and peptic ulcer disease, confirmed by a review of medical records and medication intake. Dietary habits were assessed by asking respondents to state quantity and frequency for consumption of: meat and chicken (1 serving = 70 g), eggs (1 serving = 1 egg) and dairy products (1 serving = 8 oz or 1 cup of milk or yogurt or 35 g white cheese), and whether they were strict vegetarians (i.e. vegan, eating a diet of exclusively vegetable origin). Participants were also asked if they suffered from tiredness, fatigue, numbness or paraesthesias, impaired memory, irritability or depression to assess symptoms of possible.

3 Eastern Mediterranean Health Journal, Vol. 15, No. 4, Fasting blood samples were collected from each patient for the measurement of haemoglobin level (normal: females 14 ± 2 g/dl, males 16 ± 2 g/dl; low: females < 12 g/dl, males < 14 g/dl), ferritin level (normal: females μg/l, males ug/l), folic acid level (normal: > 2.5 ng/ml), mean corpuscular volume (high: > 100 fl, normal: fl, low: < 80 fl) and peripheral blood smear (normal; hypochromic; hypersegmented). Serum vitamin level was measured by chemiluminescent microparticle immunoassay (Abbot Laboratories, Illinois, United States of America). The range of the assay is pg/ml. Using the reference range provided by the manufacturer, participants were divided into 3 groups according to level: normal (> 300 pg/ml), ( pg/ml), vitamin (< 180 pg/ml). The data were analysed using SPSS, version 11.0 for Windows. Cross-tabulation and chi-squared tests were used to evaluate the variables that can influence vitamin level or predict the presence of. Statistical significance was set at P < Results The results were based on analysis of 838 patients 280 (33.4%) males and 558 (66.6%) females seen at the family medicine and diabetic foot clinics at Jordan University Hospital. The number of women was greater than men as they attend facilities more often than men as patients and as the companions of patients. Table 1 shows the demographic features in relation to serum levels of vitamin. Deficiency (< 180 pg/ml) was detected in 374 patients (44.6%). The frequency of was 51.8% among the age group years and was higher in men (52.1%) than in women (41.0%) (P < 0.001). ( pg/ml) was seen in 287 patients (34.2%), more in women (36.0%) than in men (30.4%). There was no significant association between serum level of vitamin and the clinical signs of (fatigue, numbness), except for memory impairment, which was found in significantly more patients with than other patients (P < 0.05) (Table 2). More patients with normal ferritin level were found to be Table 1 Serum vitamin levels according to age and sex Variable Total Normal P-value Age (years) > Missing 12 Sex Female Male Total

4 856 La Revue de Santé de la Méditerranée orientale, Vol. 15, N 4, 2009 deficient than those with low ferritin level (Table 3). There was no statistically significant relationship between serum levels of folic acid and levels. No significant association was found between vitamin level and hypertension, coronary artery disease or peptic ulcer disease (Table 4). Patients with diabetes and hyperlipidaemia had significantly higher levels than nondiabetic patients or patients with normal lipid profile (P < 0.01 and P < 0.05, respectively). Low meat intake and strict vegetarian diets were associated with (P < 0.05) (Table 5). Patients who ate meat less than twice per month were more likely to have vitamin (56.4%) than those who ate meat daily (43.3%). Discussion Severe (< 180 pg/ml) resulting in neurological and haematological manifestations is comparatively rare, especially in developed countries such as the United States of America and European countries [10,11]. However, suboptimal serum levels of vitamin () are common and the prevalence is rising among lactovegetarians and patients older than 60 years [12]. In North America the is particularly observed in elderly, institutionalized patients [10,13]. The frequency of vitamin in this study was 44.6%. This is similar to a previous report from north Jordan on 216 healthy individuals by Fora and Mohammad where a suboptimal (< 222 pg/ml) serum level of was observed in 48.1% of patients [14], and also similar to reports from Israel by Masalha et al. (49%) and Gielchinsky et al. (31%) [15,16]. Similar reports of high prevalence in this region came from Turkey (46.8%) [17] and the Islamic Republic of Iran (26.7%) [18]. These are higher than the reported global prevalence, which ranges from 3% to 40% of the adult population [3 7]. Some evidence suggests that this variation is mainly related to ethnic variations, dietary habits, geographical variation and intestinal malabsorption problems, or to different cut-off values for serum vitamin level in the definition of [17,18]. Most reported studies have shown a gradual rise in the incidence of vitamin with age. In our study, the highest frequency of was observed in Table 2 Symptoms related to vitamin and serum vitamin levels Variable Total (n = 838) Normal (n = 177) (n = 287) (n = 374) P-value Fatigue Yes No Numbness Yes No Memory impairment Yes No

5 Eastern Mediterranean Health Journal, Vol. 15, No. 4, the age group years (51.8%), while was mostly observed in patients aged > 64 years (44.4%). These results were based only on levels, without measuring methylmalonic acid and/or homocysteine, which was a limitation to this study. We also noted that men had lower levels of vitamin compared to women. The same result has been noted in other studies [14,18]. Our study demonstrated a negative correlation between diabetes and vitamin (P < 0.01) and between hyperlipidaemia and (P < 0.04). Diabetic patients and patients with hyperlipidaemia were less likely to have. Similar to the results reported by Fora and Mohammad from northern Jordan [14], the values of several haematological parameters were normal in most patients and there were no obvious clinical manifestations of vitamin in this study. This could be explained by a mild and early form of according to Herbert s classification [19]. Mild memory impairment was the only clinical manifestation correlated with vitamin (P < 0.02). Reports of mental disturbances are frequent and are Table 3 Haematological parameters and serum vitamin levels Variable Total (n = 838) Normal (n = 177) (n = 287) (n = 374) P-value Haemoglobin level a Low Normal Folic acid level b Low Normal Ferritin level c Low Normal Mean corpuscular volume d High Normal Low Peripheral blood smear Normal Hypochromic Hypersegmented a Normal: females 14 ± 2 g/dl, males 16 ± 2 g/dl; low: females < 12 g/dl, males < 14 g/dl. b Normal: > 2.5 ng/ml. c Normal: females μg/l, males μg/l. d High: > 100 fl; normal: fl; low: < 80 fl.

6 858 La Revue de Santé de la Méditerranée orientale, Vol. 15, N 4, 2009 sometimes the only neurological manifestations of vitamin [1,2,20 22]. We observed a 56.4% rate of vitamin among patients getting less than 2 servings of meat per month compared with 43.3% in those who ate meat on a daily basis. This measure relied only on patients estimates of the amount eaten, which is a limitation of the study, although we tried to minimize this by cross-referencing the servings they reported to culturally-determined servings in order to validate the amount of meat consumed. The validity and reliability of respondents reporting has always been questioned. It is surprising that 43.3% of those who ate meat daily had vitamin values < 180 pg/ml; this may be related to absorption problems, which needs further evaluation. In this study, vitamin was also noted among 62.3% of strict vegetarians compared with 43.4% of nonvegetarians, suggesting that nutritional is an important cause of low serum levels of vitamin. The only current mass public health control and prevention of micronutrient deficiencies in Jordan depends on iron and vitamin A fortification of bread, in addition to dispensing multivitamin and mineral tablets weekly to students at public elementary schools. This study looked at a sample drawn from attendees at 1 hospital in the capital city, so the results cannot be generalized to Jordan as a whole. However, the results may have important public health consequences and warrant further research in collaboration with the Jordanian Ministry of Health and WHO to evaluate status in Jordan as a whole and to develop a strategy to correct this problem if similar results are found at a national level. Table 4 Presence of chronic diseases and serum vitamin levels Variable Total (n = 838) Normal (n = 177) (n = 287) (n = 374) P-value Diabetes mellitus Yes No Hypertension Yes No Coronary artery disease Yes No Hyperlipidaemia Yes No Peptic ulcer disease Yes No

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